Factual reason behind using 1:10000 over 1:1000 Epi in Cardiac Arrest

[usalsfyre]

I am seeking the science/research supported info so I have an educated/case supported basis to speak from. Don't want to continue with the old paradigm blind leading the blind.

That's what I'm saying, I don't think you'll find any. Your giving the same dose at the same administration rate, just in a slightly different concentration. It's also difficult to show one concentration as being superior to the other when the drug itself hasn't ever shown effectiveness in the first place.

You could give me the vial above and it would pretty well inspire no change in my practice. In fact, I'm firmly convinced you could take epi out of ACLS completely and not have a change in cardiac arrest survival to discharge.

I know this isn't what your looking for, but if you look into the data on epi you'd see that studying this is like rearranging deck chairs on the Titantic.

 

[sir.shocksalot]

when the drug itself hasn't ever shown effectiveness in the first place.

Out of curiosity, what makes you think Epi has no effect on cardiac arrest? I was under the impression that Epi was one of the only (if not the only) drug that had any proven benefit in cardiac arrest as a pressor.

I understand the thoughts of long term outcomes, and from my understanding thats really where we (as medical providers in general) are falling flat on our faces for cardiac arrest. However, I have always heard and read that Epi is a really important drug for arrests.

Not trying to be argumentative, I just want to see what your thoughts are.

 

[mgr22]

Out of curiosity, what makes you think Epi has no effect on cardiac arrest? I was under the impression that Epi was one of the only (if not the only) drug that had any proven benefit in cardiac arrest as a pressor.

I understand the thoughts of long term outcomes, and from my understanding thats really where we (as medical providers in general) are falling flat on our faces for cardiac arrest. However, I have always heard and read that Epi is a really important drug for arrests.

Not trying to be argumentative, I just want to see what your thoughts are.

I think the point is that epi administered during cardiac arrest has not been shown to improve survival to discharge. From the 2010 ACLS literature: "...there is no placebo-controlled study that shows that the routine use of any vasopressor during human cardiac arrest increases survival to hospital discharge."

 

[usalsfyre]

I think the point is that epi administered during cardiac arrest has not been shown to improve survival to discharge. From the 2010 ACLS literature: "...there is no placebo-controlled study that shows that the routine use of any vasopressor during human cardiac arrest increases survival to hospital discharge."

Bingo. We've been giving epi on expert recommendation since the beginning of ACLS. If it was going to work, we would have seen an outcome difference by now. It may be important in certain settings, but the "all epi all the time" philosophy that's currently being followed is not helpful and probably harmful. To vaguely quote Rogue Medic "we don't give epinephrine to STEMI patients when they're alive, what changes when they're dead"

 

[CUjays34]

Bingo. We've been giving epi on expert recommendation since the beginning of ACLS. If it was going to work, we would have seen an outcome difference by now. It may be important in certain settings, but the "all epi all the time" philosophy that's currently being followed is not helpful and probably harmful. To vaguely quote Rogue Medic "we don't give epinephrine to STEMI patients when they're alive, what changes when they're dead"

Not for nothing but organized electrical activity! Epi can prolong that activity in VF pulseless V-Tach so defibrillation can take place.

 

[usalsfyre]

Not for nothing but organized electrical activity! Epi can prolong that activity in VF pulseless V-Tach so defibrillation can take place.

Even though the most common cause of vfib is AMI?

Remember, it's not about delivering a pulse to the ED...

 

[18G]

Without a pulse though there isn't anything to work with. Getting a pulse is a step in the right direction.

 

[usalsfyre]

Without a pulse though there isn't anything to work with. Getting a pulse is a step in the right direction.

Ehhh, maybe...

Resuscitating someone who in all likelihood will be planted in a vegetable patch or die 48 hours later isn't good medicine.

 

[18G]

Ehhh, maybe...

Resuscitating someone who in all likelihood will be planted in a vegetable patch or die 48 hours later isn't good medicine.

I agree and a lot of arrest patients are just old and well... its just their time to die so no matter what we do it doesn't make a difference.

But there are some who can be resuscitated and have a return to a normal quality of life. Unfortunately we aren't able to determine very well who does return to a good quality of life and who doesn't.

 

[rogersam5]

Epi is no different from any other drug. For instance I have carried Midazolam in 10mg in 1ml (1:100 solution) and 5 mgs in 5mls (1:1000) solution. If I give 0.5mls of the 10 in 1 and 5mls of the 5 in 5 have I not given the EXACT SAME DOSE?.

Yes but with a 10 fold difference in concentration, that 10 fold difference in concentration can make a large difference in local effects through sheer pharmicokenetics. Not having any experimental data I couldn't say if there actully is a scientific reason to use 1:10000 over 1:1000. but I woul speculate the reason ould revolve around without having normal blood circulation to move the drug when injected (and thus diluting it) you would do significantly more harm injecting 1:1000 as you would see (asuming 1st order kenetics) a 10 fold increase in the rate of local vasoconstricution compaired to 1:10000. If the kenetics are a higher order your looking some significant increases is kinetics.

 

[usalsfyre]

Yes but with a 10 fold difference in concentration, that 10 fold difference in concentration can make a large difference in local effects through sheer pharmicokenetics. Not having any experimental data I couldn't say if there actully is a scientific reason to use 1:10000 over 1:1000. but I woul speculate the reason ould revolve around without having normal blood circulation to move the drug when injected (and thus diluting it) you would do significantly more harm injecting 1:1000 as you would see (asuming 1st order kenetics) a 10 fold increase in the rate of local vasoconstricution compaired to 1:10000. If the kenetics are a higher order your looking some significant increases is kinetics.

Epi 1:1000 is used exclusively for arrest in other parts of the world. Their patient's limbs are not falling off. You should be flushing any drug you give in an arrest patient, no matter the concentration.

 

[usalsfyre]

But there are some who can be resuscitated and have a return to a normal quality of life. Unfortunately we aren't able to determine very well who does return to a good quality of life and who doesn't.

Which is why resuscitation requires more thought than the most cookbook of cookbooks, the ACLS algorithm. "Push epi on every arrest" completely ignores good sense. These patients very often had medical conditions that administering epinephrine to would be considered malpractice when they had a pulse. What do you think is going to happen if there is a ROSC and the epi that has likely not made it to central circulation hits the patients vital organs?

I don't have a problem with epi as a vasopressor, but it needs to be given at vasopressor doses, a few (2-10)mcg a min. 1 milligram is quite honestly, an overdose.

 

[Ecgg]

Epinephrine shortage

Something to consider

So in 2010 Agencies were advised about Epinephrine shortages. A quick look online tells that many agencies all passed the same memos stating the following:

EPINEPHRINE SHORTAGE
Due to manufacturing and approval issues, prefilled one (1) mg epinephrine syringes 1:10,000 are on back order and may be difficult to obtain. Shipments were expected by the first part of July 2010, but there is no guarantee.
If you do not have epinephrine prefilled syringes for use, please follow these procedures for dilution of epinephrine to obtain a 1:10,000 concentration for use in cardiac arrest patients:
•
Draw up on (1) mg of epinephrine from an epinephrine 1:1000 ampule. This is one (1) mL of volume
•
Add to the epinephrine nine (9) mL of normal saline from a vial or the IV line.
•
The resulting ten (10) mL solution may be used in place of a prefill.
EPINEPHRINE IS A HIGH ALERT MEDICATION AND MAY CAUSE SIGNIFICANT PATIENT HARM WHEN USED IN ERROR; THE FOLLOWING STEPS SHOULD BE FOLLOWED TO MINIMIZE THE POTENTIAL FOR ERROR:
•
Have another crew member confirm the dilution
•
Do not save the solution or prepare it in advance
•
Use of the one (1) mg ampule is recommended
•
It is better if you always prepare the dilution using the same source of epinephrine to avoid confusion
If you have multi-dose vials of 1:1000 epinephrine make sure you DO NOT draw up 9 mL of epinephrine solution. We recommend the epinephrine solution for dilution and normal saline should be kept together in a clear plastic “baggie” with a label on the epinephrine that says one (1) mL use, along with the 10 mL syringe and brief instructions for dilution.

http://www.mvemsa.com/Drug Shortage Memo.pdf

If you search online you will find many of such advisories for multiple agencies.

Why go with the time of dilution on a code if you can just push 1:1000 and follow up with a flush. Just some food for thought...

 

[rogersam5]

Ithink the big problem they talkabout there is giving the wrong dose (1mg vs 9mg) by drawing up too much rather then the wrong dilutions being given

 

[Ecgg]

Ithink the big problem they talkabout there is giving the wrong dose (1mg vs 9mg) by drawing up too much rather then the wrong dilutions being given

Sure that aspect is included. However I seen a few where that is not mentioned.

http://www.mlrems.org/e107_files/downloads/advisory_10-11_epinephrine_shortage-2.pdf



My only observation is that, if 1:1000 amps and 1:10000 do the same job in a cardiac arrest, why waste time diluting? When I can just draw up 1mg/1ml epi bolus it and follow up with bolus pre made NS flush

 

[usalsfyre]

Why go with the time of dilution on a code if you can just push 1:1000 and follow up with a flush. Just some food for thought...

Perhaps because EMS is extremely rigid in its thought process and so hung up on following protocols we forget what we're trying to accomplish? Perhaps because the administrators writing this stuff don't really understand it? Perhaps because we're so scared of a dead person suing us from extravasation we do stuff that doesn't make sense?

I don't know the reason. As noted above other parts of the world have no prefills and haven't seen an issue.

 

[usalsfyre]

Has your agency stopped carrying prefills and your trying to get them back?

If your really worried about time, grab a 50ml syringe, pull off 5mls if epi from the multidose vial you mentioned you carried, then draw up 45mls of saline. Walla, enough epi 1:10000 to work an arrest for 20 minutes.

 

[Ecgg]

Has your agency stopped carrying prefills and your trying to get them back?

If your really worried about time, grab a 50ml syringe, pull off 5mls if epi from the multidose vial you mentioned you carried, then draw up 45mls of saline. Walla, enough epi 1:10000 to work an arrest for 20 minutes.

Absolutely not. The prefills and 30mg/30ml vials, single use vials are of plenty. Speaking with seasoned medics and physicians I herd different things regarding this matter. I just wanted to see if there is any evidence to all this.

 

[usafmedic45]

I've done it and never noticed a difference between the two, they all get jittery as hell.

Same here. I'm thinking it's a selection bias he is seeing there.

 

[Melclin]

I agree and a lot of arrest patients are just old and well... its just their time to die so no matter what we do it doesn't make a difference.

Its not about age, its about not continuing to perpetuate uselessly modalities that are as useless as they are expensive. Epi itself is of course not expensive. What I'm getting at is that idea of pumping enough juice into a corpse to create a pulse, get to ED use resources, time, beds, maybe even and ICU, if everyone who needed epi to get a pulse dies anyway. Its like how some traumatic Asystole and PEA < 40 survive to hospital, some even make it to the ICU, but none survive to discharge, so why waste the considerable resources?

I've seen services that carry vials of "high-dose" 1:1000 epi when it had to be given down an ET tube so your not putting all that fluid into the lungs with the pre-filled 1:10,000 syringes. But I have never heard of 1:1000 epi EVER being given IVP.

Maybe I'm not hearing you correctly, but several high-profile and lethal cases have resulted from 1:1000 epi being given IVP instead of 1:10,000. And hospitals and EMS services are always cautioned about having the epi concentrations marked appropriately so there is no chance for the wrong concentration to be administered.

Mate, you need to break out the old junior school chemistry notes about solutes, solvents and concentration.

Marking concentrations is important because it has implications for dosage. The concentration itself is not generally that important.

We don't carry 1:10000 adrenaline, or pre-filled syringes. Usually the done thing is to draw up several mgs into a 3,5 or 10ml syringe and give 1mg (1ml) increments, flushed though by opening your fluid for a few moments.